Quality Payments – Patient safety report
Quality Payments – Patient safety report
Please note, the interim Quality Payments Scheme for the first six months of 2017/18 has now ended. No decisions have been made by the Department of Health and Social Care and NHS England on the future of Quality Payments beyond the first six months of 2018; this will be a matter for discussion with PSNC, once substantive negotiations for 2018/19 commence.
Community pharmacy contractors passing the gateway criteria will receive a Quality Payment if they meet one or more of the quality criteria. One of the quality criteria is:
‘A written safety report (updated since 24 November 2017 i.e. the last review date where claimed before) at premises level available for inspection at review point, covering analysis of incidents and incident patterns (taken from an ongoing log), evidence of sharing learning locally and nationally, and actions taken in response to national patient safety alerts.’
Click on a heading below for more information.
NHS England guidance
NHS England has published new guidance ahead of the June 2018 review point of the Quality Payments Scheme:
- NHS England – Pharmacy Quality Payments Guidance for the June 2018 Declaration (published 30th April 2018).
The June 2018 guidance should be read in conjunction with NHS England’s gateway criteria guidance and the quality criteria guidance:
- NHS England – Pharmacy Quality Payments Gateway Criteria Guidance (published 23rd December 2016); and
- NHS England – Pharmacy Quality Payments Quality Criteria Guidance (published 27th February 2017).
These documents are available on the NHS England website.
PSNC strongly encourages all contractors to read the new NHS England guidance, as well as the previous guidance, to ensure they are fully briefed on the requirements of the Quality Payments Scheme ahead of the June 2018 review point.
Quality criterion points and value
The value of this quality criterion is as follows:
|Total points for the June 2018 review point||20|
|Value of total points||£640-1280*|
*The funding will be divided between qualifying pharmacies based on the number of points they have achieved. Each point will have a minimum value worth £32 and a maximum of £64.
Aim/rationale of this quality criterion
The aim of this criterion is to foster a culture of learning and continuous improvement in every pharmacy with regard to patient safety. It is based on the following principles that have been developed in collaboration with community pharmacy Medication Safety Officers (MSOs) and stakeholders, to support the production of the written patient safety report. These are complementary to the principles of incident reporting which can be found on the Community Pharmacy Patient Safety Group website.
- Incidents to be considered in the report should include errors or near misses that involve medication that have caused patient harm or had the potential to do so. Errors picked up early in the dispensing process or documentation errors would therefore not be included.
- The aim of a pharmacy written patient-safety report is to recognise and support development of a safety culture. In particular, the report should demonstrate continuous improvement through reviewing and reflecting on errors.
- Where errors occur, a proportional response to changes and safety measures should be taken. Contractors should take care that in focusing on one area for improvement, they are not neglecting others.
- Where human intervention is involved, the potential for error exists. Using systems and processes to support staff to make the correct decision or take the right action improves safety. Care should be taken in developing these processes so that they are user friendly, otherwise they risk not being followed correctly, increasing the risk of error.
- The best barriers to error are the simplest and often rely on physical measures.
Error occurs when a complex set of circumstances converge and make it possible. Understanding the relationships between circumstances requires the gathering of information, followed by analysis and reflection. This is why it is important that contractors review errors and share their learning.
Since 2005, community pharmacies have been required to record patient safety incidents in an incident log and report these to the National Reporting and Learning System (NRLS).
How to achieve this quality criterion (includes template reports)
The written safety report should be specific to each individual pharmacy and should be a summary that reflects the events taking place in that pharmacy. Contractors are encouraged to work with other pharmacies to share their learning.
Contractors who claimed for this quality payment in 2017 will not be able to use the same patient safety report to make a claim in June 2018. For the June 2018 declaration they will need to update their previous report to show how the following have been updated and refreshed since their 2017 patient safety report was completed.
In order to meet this quality criterion, contractors should:
- collate incidents and near misses from an ongoing log;
- analyse these and look for patterns;
- reflect on the learning from these;
- take actions to minimise future risk from repeated errors; and
- share their learning (both locally and nationally).
This should then be documented in a written patient safety report. Incidents to be included in the report should include errors or near misses that involve medication that have caused patient harm or had the potential to do so. Errors picked up early in the dispensing process or documentation errors would therefore not be included.
The report must also include evidence of specific actions taken by the pharmacy in response to local errors and national patient safety alerts issued by the Central Alerting System.
PSNC, the Community Pharmacy Patient Safety Group and NHS Improvement have created the below templates, which contractors may choose to use to create their report; these templates are also included in Annex 1 of the NHS England guidance on the quality criteria.
A template to collate and review patient safety incidents each month:
A template to complete the annual written patient safety report:
The report does not need to be submitted to NHS England routinely but contractors should ensure that a copy of the report is kept in the pharmacy.
Examples of completed monthly and annual forms can be found below:
Completing the written report
PSNC and the Community Pharmacy Patient Safety Group have published a resource which explains how contractors can use the monthly and annual template patient safety reports to meet the quality criterion and lists questions and examples which pharmacy teams can consider to help them complete the report.
There are several different ways that contractors can share learning locally. This might take the form of a meeting with local general practices to share learning from incidents or near misses, sharing learning with other local pharmacies, a Local Pharmaceutical Committee (LPC), Local Professional Network (LPN) or Local Practice Forum (LPF) event, or sharing via a newsletter.
PSNC has developed a Patient safety information page that contains a quick reference guide to patient safety alerts, recalls, advice and guidance relating to patient safety which have previously been highlighted as news stories on the PSNC website and a link to the Medicines and Healthcare products Regulatory Agency (MHRA) monthly drug safety updates.
The declaration process
Contractors will be required to declare through the NHS BSA online declaration page (this webpage is not live yet) that they meet this quality criterion.
Q. Does completion of the patient safety report replace the need to report patient safety incidents to the National Reporting and Learning Service?
No. Reporting patient safety incidents to the National Reporting and Learning Service (NRLS) is a contractual responsibility and pharmacy teams should continue to do this.
Q. What duration of time should my pharmacy’s written safety report cover?
While NHS England has not defined a time period, it is expected that the written safety report should cover the previous 12 months if possible. To meet the June 2018 review point, contractors that previously wrote a report for either of the 2017 review points must have updated that written safety report since 24 November 2017 (the last review point).
Contractors should have records of incidents, near misses and responses to medicines recalls and national patient safety alerts that would allow them to complete an annual patient safety report retrospectively and reflect on learning from these.
Q. Is there a template patient safety report that must be used to meet this quality criterion?
A template patient safety report is available on the Quality Payments – Patient safety report page; however, contractors do not have to use this template to meet this quality criterion. If contractors choose to create their own report, they should ensure it includes all the information required by NHS England. Details on the requirements can be found on the Quality Payments – Patient safety report page.
Q. Does the written patient safety report need to be submitted to NHS England?
No. The report does not need to be submitted routinely to NHS England, but contractors should ensure that a copy of the report is kept in the pharmacy.
Q. The quality payment criterion states that a ‘written’ safety report at premises level needs to be available for inspection; does this need to be handwritten or can it be computer generated (typed)?
The report can be either hand written or computer generated (typed).
Further FAQs on the Quality Payments Scheme can be found on the Quality Payments – FAQs page.